AP Therapeutic Practice- New Client Information
Please complete the following information. We will verify your insurance benefits and send you an email with your estimated cost of services. 

If you have any questions please call 601-207-0774
Sign in to Google to save your progress. Learn more
What type of service are you seeking? *
Are you interested in in-person therapy or telehealth (video sessions)? *
What is your availability for therapy?  *
Required
Client's Legal First Name *
Client's Legal Last Name *
Client's Preferred Name (If different)
Client Date of Birth *
MM
/
DD
/
YYYY
Client's Phone Number
Email Address to put on file (if minor, please provide guardian's email)  *
If a Minor; Legal Guardians First/Last Name (NA if not applicable) 
If a minor; legal guardians phone number (NA if not applicable) 
Address: Street *
Address: City *
Address: State *
Address: Zip Code *
Insurance Company Name *
Insurance Member ID #
 *
Insurance Group #
 *
Insurance Company Contact Number (located on the back of the card)
Insurance Subscriber First Name 
 *
Insurance Subscriber Last Name *
Insurance Subscriber Date of Birth (If different than the client)
MM
/
DD
/
YYYY
Insurance Subscriber Phone Number (used to file claims)
 *
Insurance Subscriber Address ( If different than the client)
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of aptp.info.

Does this form look suspicious? Report

Google Forms